Provider Demographics
NPI:1336895275
Name:PETTIT, KIMBERLY K (RBT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:PETTIT
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 GLENN AVE
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-6109
Mailing Address - Country:US
Mailing Address - Phone:609-218-8664
Mailing Address - Fax:
Practice Address - Street 1:76 W JIMMIE LEEDS RD
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9411
Practice Address - Country:US
Practice Address - Phone:609-339-9012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-15-18539106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty